20180738 Ver 1_Shoreline Stabilization_20180524

20180738
State of North Carolina
Department of Environment and Natural Resources
Division of Water Resources
Dlvlsl' of er rtes 15A NCAC 02H.0500 — Water Quality Certification, Shoreline Stabilization
FORM: SSGP 10-2013
Shoreline Stabilization Application Form
Three copies of the application (including attachments) and the application fee should be sent
to:
Division of Water Resources
401 & Buffer Permitting Unit
1617 Mail Service Center
Raleigh, NC 27699-1617 t4Ar V
���� '� 4
PFA1018
I. Applicant Information [15A NCAC 02H .0502(a)] &r IP p
1. Owner Information _ �rIEP,CP �'
Name: t , Eno f"1ry
Mailing Address: /5 70o K oi/Srnl7/ .1 pa7aac Ltn<z
01a r /-a /& N(_ 9-Z77
Telephone Number: 70 300 Z— Fax Number:
E-mail Address:tdjE/�tr F7 --T K14A- M7,1: r �e
2. Agent/ Contact Person Information
A signed and dated copy of the Agent Authorization letter (a form can be downloaded here:
http://www.saw.usace.army.mil/Portals/59/docs/regulatory/`regdocs/Permits/SAMPLE AGENT AUTH
ORIZATION FORM.pdf) must be attached if the Agent has signed this application form.
Name:
Company Affiliation:
Mailing Address:
Telephone Number: Fax Number:
E-mail Address:
Person to receive the Certification Approval:
II. Project Information [15A NCAC 02H .0502(a) & (b)]
1. Attach a vicinity map (i.e. street map) clearly showing the location of the property with
respect to local landmarks such as towns, rivers, and roads.
2. Provide a detailed site plan showing property boundaries and proposed locations of
vegetation clearing, structures (buildings, retaining walls, docks, impervious surfaces,
FORM: SSGP 10-2013 Page 1 of 3

etc.), rip rap, excavation or dredging below Full Pond/ Normal Water Level elevations,
and construction access corridors. You may use the diagram provided at the end of this
application form.
3. Attach a photograph of the shoreline/ buffer proposed to be stabilized. (Include a scale
of some sort- a yard stick, shovel handle, etc.)
4. Location of the pro erty (where work is to be conducted)
County: mel_ — Nearest Town:
Subdivision name or saddress (include phase/lot number):
Directions to site - please include road names and numb s dmarks, etc.:
Or
Latitude (in decimal degrees)�Longitude (decimal degrees) U70�c�
5. Describe the existing land use or condition of site at the time of this application
(residential, undeveloped, etc.): NS Gi
6. Property size (acres):
7. Lake/ river/ ocean adjacent to property:�_�
8. Describe proposed work (include discussion as to how ha dening of sh reline has been
avoided, or why it is necessary):
9. Will work be conducted from land? From water? El
10. Total amount of disturbance (including all excavation, backfill, rip rap, retaining walls, etc.)
below the normal poollake level/ Normal ater Level in square feet or acres:
U
11. Total amount of disturbance (including all clearing, back fill, excavation, rip rap, retaining
walls, etc.) above the normal pool lake level/ Normal Water Level and 50 feet land -ward in
square feet or acres:
12. Please describe the vegetation above the normal pool lake level/ Normal Water Level and
50 feet landward to be i acted u ber of ees, for instance
//CZ✓S cm's /l�� Ei� � _s- d/
t
Owner/Agent's Signature [15A NCAC 02H .0502(f)] Date
Agent's signature is valid only if an authorization letter from the owner is provided.
FORM: SSGP 10-2013 Page 2 of 3

Norm
5
Please approximately sketch the following information on this plan (provide dimensions for each
item, such as 10 ft x 100 ft)*:
I. All proposed vegetation clearing
2. Location of rip rap or fill to be placed above the Full Pond/ Normal Water Level elevation
3. Location of rip rap or fill to be placed below the Full Pond/ Normal Water Level elevation
4. Location of any proposed structures such as buildings, retaining walls, docks, etc.
5. Location of any excavation or dredging below the Full Pond/ Normal Water Level elevation
6. Location of construction access corridors
FORM: SSGP 10-2013 Page 3 of 3

,l.U.lAL- AKBA '- --V T—fKCI E—
by coordinates
20 Q 20mm
Sob M IN rest(� ra an R 3
oo
From the elk* of
VOGHT @ FIELDS LAND SURVEYING
1340 Albemarle Rood, Suite N VV
Troy. N.C. 273711
1\i
Lake Til ery
GENERAL NOTES:
1. No horizontal control within 2000 feet
of this property.
2. This Property le not located In any
FEMA Speolal Flood Hazard Area,
iko Energy
PraPertY
Found: I
1-1/4" Iron
Pipe
Found: S/0'
Iron Rebar at
shoreline ,
Lot Now 19
MkhoN K. Dunn and Apr# M. Aran
Deed Book 791 Page 29J
Lot No. 17
.dine D. ANen
Deed Book 603 Pogo 739
MAGNET
NORTH
April 201

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